[e-drug] Sachs plenary from 'Massive Effort' meeting

Below is the text of a forceful plenary presentation by Jeffrey D. Sachs
(Director of the Centre for International Development, Harvard, USA; by
video-link) during the Massive Effort Advocacy Forum held in Winterthur,
Switzerland from October 3-6 2000 (http://www.winterthurhealthforum.ch/).

Can anybody at the CID expand on what Professor Sachs had in mind when he
referred to: 'new methods of health delivery - drawing on the new
information technologies, the schools, and the communities'?

Jeffrey D. Sachs
Director of the Centre for International Development (Harvard)
(3 October 2000)
(taken from: http://www.cid.harvard.edu/)

Ladies and Gentlemen, congratulations on the Winterthur Health Forum, and
the Massive Effort Advocacy Campaign.

I speak to you today as Chairman of the Commission on Macroeconomics and
Health, a commission established by Dr. Gro Bruntland [WHO Director-General]
earlier this year to bring together the worlds of international finance and
public health. The CMH, as we call it, will be issuing its report in 2001,
with an interim report issued later this year. At the core of CMH is a basic
idea: that the horrific disease burden of the poorest countries - claiming
millions of lives every year and billions of days of sickness - is a
fundamental barrier to economic improvement of the world's poorest people.

Perhaps three million people, mostly children, die annually from diseases
readily preventable by vaccination. Millions more die of diseases that are
preventable by other means, or that are likely targets of new technologies
in the next few years. Health is of course an end in itself, and humanity
must not stand by as millions of people suffer unnecessary, often easily
preventable deaths. But health is also an investment - in the economic
wellbeing of people at the edge of survival. Without an improvement in
public health in the poorest countries, all of the economic reform agenda,
all of the potential benefits of a fast-growing world economy - are likely
to bypass hundreds of millions of people, and leaving them and their
children in utter impoverishment.

Poor health cripples poor societies in numerous ways. Most directly, the
burdens of illness and death rob society of productive healthy workers. This
is most starkly the case in the HIV/AIDS pandemic, which is robbing Africa
of the millions of the societies? most productive members in the prime of
their lives. But the burden works through less obvious channels as well.
Children surviving multiple bouts of diarrhoeal disease, respiratory
infection, helminthic infections, and malaria, may well suffer lifetime
impairments in physical and cognitive capacities. They are more likely to
drop out of school early after repeated absences. The lifetime burdens of
illness and under-nutrition, we have learned, can start with nutrient
deficiencies in-utero, so that pre-natal care is an investment in a lifetime
of health and productivity of the yet unborn child.

Ironically, the evidence strongly suggests that the massive number of early
deaths among children - especially from malaria, diarrhoeal disease, and
respiratory infections - actually speeds population growth, rather than
slows it, with all of the attendant complications for society. This occurs
because in societies with high rates of infant and child deaths, parents
compensate the risk of death by having large numbers of children. And
because they want insurance that at least one son will reach adulthood, they
may have as many as six children when the expectation is that two will die.
Insurance for the parents, though, translates into unmanageably fast
population growth for the society, and low levels of school and health
investments in each individual child.

When health is looked upon as an investment in the future of today's poorest
people, we must stand shocked at the extent of the under-investment that we
are making. In the world's poorest countries, the national investments are a
mirror of national impoverishment. When a country at $250 per capita makes
an investment in public health of 3 percent of GDP, that translates into
annual spending of just $7.50 per person per year. This compares with public
health spending of $3,000 to $5,000 per person in the rich countries.
Critics of foreign assistance sometimes mistakenly argue that the basic
problem of health care in the poorest countries is mismanagement of health
systems. I want to reject that view categorically: there is no way to manage
an efficient health system at $7.50 per capita. And there is no way that the
world's poorest societies, just barely surviving at current income levels,
or perhaps not surviving, can manage much more than that out of their own
resources. This is especially true when debt service payments to
governments, the World Bank, and the International Monetary Fund, are
draining more than the annual budgets for health care. Yes, by all means,
countries like India and Nigeria which are spending around $3.00 in public
funds per year in public health could do more themselves. And yes, by all
means, countries should strive to maintain efficiency and honesty in health
care delivery. But no, the poorest are the poor cannot be blamed for the
disastrous state of public health. They simply lack the resources to do
better.

And globalization is not making matters easier in this regard. Through
Africa, highly mobile doctors are leaving their countries to work in Europe,
the Middle East, and the United States. The market for skilled workers,
including skilled workers in health, has become global. Poor countries, like
it or not, will have to pay a competitive wage to their doctors if they
expect to keep them in Kano, Nigeria, or Arusha, Tanzania, or Kerala State
in India. The squeeze on skilled labor will therefore get worse, not better,
unless we do something about it.

The rich countries will have to help square the circle through a massive
effort of support at disease control. The numbers can not add up in any
other way. But thank goodness, very modest efforts by the standards of the
rich countries can make a manifold difference for the poorest of the poor.
The rich countries today, are unimaginably rich even by standards of twenty
ears ago. The U.S. average income is $30,000 per year, signifying a $10
trillion dollar economy. The capital gains in the U.S. stock markets in the
past five years are an astounding $8 trillion. There are now 1 billion
people in rich countries enjoying a standard of living unrivalled in world
history. Make no mistake about it, however, despite thirty years of public
pronouncements about disease control, despite an international pledge of
"Health for All in the Year 2000" made a generation ago, the rich-country
support of health for the poorest of the poor is at shockingly low levels.
These are levels, ladies and gentleman, are even below what you might
imagine.

The Organization for Economic Cooperation and Development (OECD), in Paris,
keeps careful records of all official development assistance (ODA) by the
rich countries and by the international institutions on behalf of the
poorest countries. The numbers are shocking. In the category of Basic
Health, which includes provisions for infectious disease control and support
for primary health clinics, the total grants in 1998 from all donors - both
governments and international agencies - for all 619 million people in the
least developed countries was $209 million, or around 30 cents per person in
the poorest countries. Even this exaggerates the real aid, however, since
$21 million of this was tied aid and $88 million was so-called technical
assistance, paying experts in the rich countries rather than providing
cash-support to the poor countries. In fact, only $78 million came in the
form of untied cash support for the poorest countries, around 13 cents per
person in the recipient countries, and around three-ten thousandths of one
percent of the income of the rich countries . . . one or two minutes per
year worth of rich-country income.

The level of support for HIV/AIDS is equally shocking, totalling a few tens
of millions of dollars per year for the poorest countries, while the
greatest pandemic in modern history, perhaps in world history, has unfolded
before our eyes.

The work of the Commission on Macroeconomics and Health is devoted to
understanding the areas of highest social return to new international
investments in public health in the poorest countries, and to providing a
serious estimates of the sums that will be needed as well as potential
delivery mechanisms. That work will not be completed for one year, but we re
far advanced in several aspects of the undertaking. We have identified major
disease areas - including HIV/AIDS, malaria, TB, diarrhoeal disease, acute
respiratory infection, helminthic infections, nutritional disorders,
reproductive health -- as the likely targets of effective intervention, and
have begun to prepare detailed cost estimates for providing the population
with existing technologies of prevention and treatment, as well as cost
estimates for new research priorities where new technologies are urgently
needed. I can safely say, speaking personally and with preliminary data,
that international support for disease control can and should reach $10 to
$20 billion per year from the richest countries, still a mere $10 - $20 per
person per year in the rich countries. This must be accompanied by
comprehensive debt cancellation for the world's highly indebted poor
countries. With debt cancellation and a greatly increased level of spending,
millions of lives can be saved, untold suffering can be relieved, and
economic development prospects of the world's poorest countries can be
enormously enhanced. And even the sum of $10-$20 billion per year would be
less than one-tenth of one percent of the incomes of the rich countries.

Increased spending should be combined with new methods of health delivery -
drawing on the new information technologies, the schools, and the
communities - in innovative ways. So too, the worldís scientific community
and the leading pharmaceutical and biotechnology companies must be induced,
often through novel means such as "guaranteed purchase funds for vaccines"
to devote much more of their astounding scientific prowess to the urgent,
life-and-death needs of the world's poorest peoples. The donors will also
need a new form of cooperation, not simply more funding. They will need to
pool resources, rather than segregate them in pet projects. They will need
to give up turf in a common battle against disease. They will need to turn
to the independent scientific community for intensive, high-level, ongoing
scrutiny, at every stage of the process. Independent panels of scientific
experts should review disease control proposals coming from the
international community, especially welcoming proposals coming from the
affected countries themselves. These panels should emphasize scientific
rigor, peer-review, and independence, to ensure the highest scientific
standards in our new Massive Effort against disease. The World Health
Organization has a unique role to play in this in convening this expertise,
since WHO is the leader of global public health and the world's foremost
bridge between the official donor community and the worlds of medical
science and public health.

In closing, I congratulate you again on your remarkable contributions to the
new Massive Effort for Disease Control. This is a high calling for all
humanity. The benefits for our world, for our children, will be enormous.
You are to be deeply praised for all your efforts.
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